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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317363
Report Date: 05/15/2024
Date Signed: 05/22/2024 04:02:36 PM

Document Has Been Signed on 05/22/2024 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:UNITED CEREBRAL PALSY OF SAN JOAQUINFACILITY NUMBER:
390317363
ADMINISTRATOR/
DIRECTOR:		RAY CALLFACILITY TYPE:
775
ADDRESS:333 W. BENJAMIN HOLT DRIVETELEPHONE:
(209) 956-0290
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 70CENSUS: 34DATE:
05/15/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:52 AM
MET WITH:G.LopezTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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On 5/15/2024, Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with G. Lopez and explained the purpose of the visit. Later joined by Shirley Ridoloso.

LPA inspected the physical plant including but not limited to the kitchen, activity rooms, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. Hot water temperature was measured at 107.5 degrees Fahrenheit in Consumer bathroom sink, which is within the required range of 105 to 120 degrees. Fire/disaster drill was conducted on 2/26/24.

Fire extinguishers and smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 5 consumer/resident and 6 staff files, including criminal record clearances. LPA observed carbon monoxide detectors in the facility. Residents file review observed 2 of 5 restricted health care plan were out of date.

Per the Title 22, Division 6 of California Code of Regulations. Deficiencies were observed during today's inspection.

Exit interview conducted.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2024 04:02 PM - It Cannot Be Edited


Created By: Albert Johnson On 05/15/2024 at 01:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: UNITED CEREBRAL PALSY OF SAN JOAQUIN
FACILITY NUMBER: 390317363

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)

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Type B
05/29/2024
Section Cited

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82092.2 Restricted Health Condition Care Plan

(a) The licensee who chooses to care for a client with a restricted health condition may use a copy of the Restricted Health Care Plan from the
client's residential setting provided that the information required in Section 82092.2(a)(4), specific to the day program, is added. If the client does not have a Restricted Health Condition Care Plan, the licensee must develop a plan.
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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